1. Name of person completing this form:
2. Provider Name:
3. Address:
4. City, State Zip:
5. E-mail Address
6. County:
7. Telephone: (ex. 888-343-3547)
8. Languages Spoken:
9. Primary Specialty:
10. Secondary Specialty:
11. Other locations:
12. Provider's Tax Identification Number:
13. Legal Entity Name
14. NPI #:
15. Is this Provider part of existing par-credentialed group?
16. Do you participate with CAQH Credentialing?
17. Hospital Affiliations:
(if not active hospital affiliation, must provide appropriate coverage arrangements)
18. Board Certified/Board Prepared:
(if not Board Certified, must show evidence of completion of a residency training or post-graduate training)
19. How did the Provider hear about Fidelis Care?
If you are a Behavioral Health Provider, please complete questions 1-19 and someone will contact you regarding additional questions to be completed.
*Note: Minimum Provider Qualifications: Valid, current license; valid current DEA certificate; completion of residency training; graduation from Medical/Professional school; certification; and hospital affiliation.
**Note: Pathologist, Radiologist, Anesthesiologists, Neonatologists, Emergency Medicine Physicians, Hospitalists, and Behavioral Health practitioners who practice exclusively within a State licensed facility (OMH or Article 28) do not have to be individually credentialed. Practitioners within these specialities who provide services independently of these facilities shall be individually credentialed.